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Acute Retention of Urine (AUR) - Complete LAQ

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Definition

• AUR = sudden, painful inability to void voluntarily despite a full bladder
• Kidneys continue to produce urine normally (unlike anuria)
• Bladder is distended, tense, and painful
• Distinguish from chronic retention (painless, gradual) and anuria (empty bladder, kidney failure)

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1. CAUSES OF ACUTE RETENTION OF URINE

A. Obstructive Causes (Most Common)

1. Benign Prostatic Hyperplasia (BPH) - single most common cause (60%+ cases)
2. Carcinoma of prostate
3. Urethral stricture - from previous infection (gonorrhoea), trauma, or instrumentation
4. Phimosis - tight foreskin obstructing urethral meatus
5. Impacted urethral calculus (stone)
6. Blood clot - from haematuria (bladder tumour, trauma)
7. Papilloma / tumour of urethra
8. Rupture of urethra - post-trauma

1. Retroverted gravid uterus (in pregnancy)
2. Pelvic masses - uterine fibroid, ovarian cyst
3. Urethral caruncle / stricture
4. Cystocele compressing urethra

1. Bladder neck obstruction
2. Vesical tumour causing clot retention
3. Prostatic / periurethral abscess
4. Constipation (faecal impaction compressing urethra)

B. Neurological Causes

1. Spinal cord injury / compression (most important neurological cause)
2. Multiple sclerosis
3. Parkinson's disease
4. Diabetic neuropathy (autonomic)
5. Tabes dorsalis (syphilitic)
6. Cauda equina syndrome

C. Post-operative / Post-anaesthetic Causes

1. After general or regional anaesthesia - very common
2. After perineal/pelvic surgery (haemorrhoidectomy, hernia repair, rectal excision)
3. Spinal anaesthesia - temporary detrusor paralysis

D. Drug-Induced Causes

1. Anticholinergics - reduce detrusor contraction (atropine, antihistamines, tricyclic antidepressants)
2. Sympathomimetics - increase urethral tone (decongestants, amphetamines)
3. Opioids/narcotics - decrease detrusor contractility
4. Epidural anaesthesia

E. Psychogenic / Reflex Causes

1. Anxiety, fear, embarrassment in hospital (cannot void in bed)
2. Painful local conditions - anal fissure, perianal abscess, acute prostatitis, acute UTI (reflex spasm)

Key statistics (Pye's Surgical Handicraft, Table 21.1 - 300 consecutive cases): BPH = 193 cases | Malignant prostate = 39 | Urethral stricture = 23 | Phimosis = 14 | Clot retention = 9

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2. CLINICAL PRESENTATION

Symptoms

1. Severe, excruciating lower abdominal pain - constant with an urgency to void
2. Inability to pass urine - complete inability (not just reduced stream)
3. Intense desire to micturate - patient is restless, distressed, writhing in pain
4. Overflow incontinence may be present in severe/prolonged cases (dribbling over a full bladder)
5. History of preceding LUTS (Lower Urinary Tract Symptoms) - hesitancy, poor stream, nocturia, terminal dribbling (suggests BPH as underlying cause)
6. History of precipitating events - recent surgery, anaesthesia, new medication, constipation

Signs

• Patient in obvious distress, may be sweating
• Tachycardia from pain

1. Visible suprapubic bulge in thin patients
2. Palpable, tense, smooth midline swelling arising from pelvis (dull to percussion)
3. Swelling is dull on percussion (bladder full of urine)
4. Pressure on the swelling increases the urge to void (pathognomonic of AUR vs. other masses)
5. Bladder may extend from pubic symphysis to umbilicus

1. Prostate enlarged, firm, smooth - suggests BPH
2. Prostate hard, nodular, irregular - suggests carcinoma
3. Bladder felt as a cystic mass pushing prostate posteroinferiorly
4. Note: Prostate size cannot be accurately assessed with a full bladder - decompress first

• Perineal sensation, anal tone, lower limb reflexes - assess for neurogenic cause
• Saddle anaesthesia suggests cauda equina syndrome (emergency)

• Phimosis, meatal stenosis, urethral discharge, external urethral opening

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3. DIAGNOSTIC MODALITIES

A. History & Physical Examination (Primary)

• As described above - usually sufficient to diagnose AUR
• Key: painful distended bladder + inability to void

B. Urine Tests

1. Urine dipstick - haematuria (clot retention, tumour, stone), pyuria (infection)
2. Urine culture & sensitivity - rule out UTI as precipitant
3. Urine cytology - if bladder tumour suspected

C. Blood Tests

1. Serum creatinine & BUN - assess for acute kidney injury (obstructive uropathy if prolonged)
2. Serum electrolytes - especially if prolonged retention causing post-obstructive diuresis
3. PSA (Prostate Specific Antigen) - elevated in BPH and prostate cancer
   • Note: PSA rises transiently after catheterization; check before or >4 weeks after
4. FBC - WBC for infection
5. Blood glucose - rule out diabetes (neurogenic cause)

D. Imaging

• First-line, immediate, non-invasive
• Confirms urinary retention
• Measures post-void residual (PVR) volume
• Volume >300 mL is significant; >150 mL post-void is abnormal
• In patients with severe liver disease, ascites can be misinterpreted as urine

• Detects hydronephrosis (upper tract obstruction in prolonged cases)
• Assesses prostate size and morphology
• Identifies bladder tumour, calculi, clots
• Measures residual urine volume
• Safe, no radiation, widely available

• Identifies radio-opaque urethral/bladder stones
• Identifies bony metastases (prostate cancer)

• If bladder tumour or complex pathology suspected
• Assesses upper tracts comprehensively

• If urethral stricture is suspected (resistance on catheterisation)
• Shows site and length of stricture before intervention

• For prostate cancer staging, spinal cord compression (MRI spine)
• MRI spine is mandatory if cauda equina/spinal cause suspected

E. Urodynamic Studies (After acute phase resolves)

1. Uroflowmetry - measures peak flow rate (Qmax); <10 mL/s suggests BOO
2. Pressure-flow study - distinguishes BOO from detrusor underactivity
3. Cystometry - assesses bladder capacity, compliance, detrusor contractions

F. Cystoscopy (After catheter insertion)

• If bladder tumour, urethral stricture, bladder stone suspected
• Can be diagnostic and therapeutic simultaneously

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4. MANAGEMENT STRATEGIES

STEP 1: Immediate - Bladder Decompression (Emergency)

A. Urethral Catheterisation (First choice)

• 14-16 Fr Foley catheter standard in most cases
• For BPH - use coudé (curved-tip) catheter 18-20 Fr - larger, stiffer catheter passes through the angulated prostatic urethra better than a small one; curved tip at 12 o'clock position
• For urethral stricture - use smaller catheter (12-14 Fr); resistance felt near meatus (most strictures are distal)
• Drain urine slowly (avoid rapid decompression)
• Haematuria - use a 3-way catheter for continuous bladder irrigation (CBl)

B. Suprapubic Catheterisation (If urethral catheterisation fails)

• Indicated when: urethral catheter cannot be passed (urethral trauma, stricture, after failed urological attempts)
• Placed 2 fingerbreadths above pubic symphysis in midline
• Use ultrasound guidance or aspiration with finder needle first to confirm bladder position
• Contraindication: previous suprapubic surgery (bowel may be adherent)

C. Urological Consultation

• If catheter cannot be passed, urologist can:
  • Use cystoscope + guidewire + dilators to dilate stricture and place Council-tip catheter (Seldinger technique)
  • Place suprapubic tube

STEP 2: Monitoring After Decompression

1. Record urine output hourly - watch for post-obstructive diuresis (high urine output after relief)
2. Check serum creatinine, electrolytes
3. Bladder scanner to confirm adequate drainage

STEP 3: Trial Without Catheter (TWOC)

• After 3-7 days (median 5 days) of catheterisation
• Catheter removed; patient attempts to void
• Success rate ~60% on first attempt
• If TWOC fails: second attempt (29.5% success) or third attempt (26.4% success)
• Patients with failed TWOC proceed to surgery

STEP 4: Medical Management (Alongside catheter)

1. Alpha-blockers (Tamsulosin 0.4 mg OD)
   • Given BEFORE TWOC for BPH
   • Relaxes prostate smooth muscle and bladder neck
   • Significantly increases TWOC success rate
   • Continue long-term to prevent recurrence
2. 5-Alpha Reductase Inhibitors (Finasteride / Dutasteride)
   • Reduce prostate volume by 20-30% (over months)
   • Reduce AUR incidence by 50% long-term
   • Not useful acutely (takes 3-6 months to work)
   • Best for large prostates (>40 mL)
3. Antibiotics - if UTI/prostatitis is precipitant
4. Treat precipitating cause:
   • Stop anticholinergic/opioid drugs if possible
   • Treat constipation
   • Spinal cord compression: urgent neurosurgical/orthopaedic referral

STEP 5: Surgical Interventions (Definitive)

For BPH:

1. TURP (Transurethral Resection of Prostate) - Gold standard
   • Endoscopic resection of obstructing prostatic tissue
   • After acute phase settled; elective
   • TWOC failure is a strong indication
2. Open Prostatectomy - for very large glands (>80-100 g)
   • Millin's retropubic or transvesical approach
3. Laser Prostatectomy (HoLEP, GreenLight PVP) - less bleeding, suitable for anticoagulated patients

For Urethral Stricture:

1. Urethral dilatation - using dilators/bougies
2. Optical urethrotomy (DVIU) - direct-vision internal urethrotomy
3. Urethroplasty - for long/recurrent strictures

For Bladder Neck Obstruction:

• Bladder neck incision (BNI) or TURP

For Neurogenic Bladder:

• Clean Intermittent Catheterisation (CIC) - preferred long-term method
  • Patient catheterises every 4-6 hours
  • Reduces infection risk compared to indwelling catheter
  • May improve bladder function

For Clot Retention:

• 3-way catheter with continuous bladder irrigation (CBI)
• Treat underlying cause (tumour, stone)

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Quick Summary Table

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Carcinoma of Bladder - Complete LAQ

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1. AETIOLOGY (Risk Factors)

A. Environmental / Chemical Carcinogens (Most Important)

1. Cigarette Smoking - SINGLE most important risk factor
   • Responsible for 50-60% of all bladder cancers
   • Tobacco contains aromatic amines (2-naphthylamine, 4-aminobiphenyl) excreted in urine
   • Risk is dose-dependent; 2-4x higher in smokers than non-smokers
2. Occupational Exposure (~20% of cases)
   • Workers in: textiles, petrochemicals, rubber, dye industries
   • Bus/truck drivers (diesel fumes)
   • Hairdressers (hair dyes contain aromatic amines)
   • Firefighters, plumbers, printers
   • Carcinogen involved: aniline dyes, beta-naphthylamine, benzidine
3. Schistosomiasis (Bilharziasis) - Schistosoma haematobium
   • Common in Egypt, Africa, Middle East
   • Causes chronic bladder irritation and inflammation
   • Associated specifically with squamous cell carcinoma of bladder
4. Ionising Radiation - pelvic radiotherapy increases risk
5. Cyclophosphamide (chemotherapy drug) - acrolein metabolite is bladder carcinogen; causes haemorrhagic cystitis and later bladder cancer
6. Phenacetin abuse (analgesic nephropathy)

B. Chronic Irritation / Infection

1. Chronic UTIs - recurrent infections lead to squamous metaplasia
2. Bladder calculi - chronic mechanical irritation
3. Indwelling catheters (long-term) - associated with squamous cell carcinoma
4. Bladder diverticula (urinary stasis)

C. Genetic / Molecular Factors

1. Age - most important independent factor; median age at diagnosis >70 years
2. Male sex - 3:1 male to female ratio
3. Family history - first-degree relatives at increased risk
4. Genetic mutations:
   • FGFR3 alterations - common in low-grade NMIBC
   • TP53 inactivation - occurs in 76% of muscle-invasive bladder cancer (MIBC)
   • RB1 loss - common in MIBC
   • HRAS mutations - oncogene activation
   • GWAS susceptibility loci: 8q24.21 (MYC), 3q28 (TP63), 5p15.33 (HTERT), 8p22 (NAT2)

D. Other Causes

1. Tryptophan metabolism abnormalities - abnormal urinary tryptophan metabolites
2. Urachal remnant - source of bladder adenocarcinoma

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2. HISTOLOGICAL TYPES

Primary Classification (Bailey & Love, Table 83.17):

A. Transitional Cell Carcinoma (TCC) / Urothelial Carcinoma - >90%

• Also called urothelial carcinoma (current WHO term)
• Arises from transitional epithelium (urothelium) lining the urinary tract
• Papillary (most common, 70%) - exophytic, frond-like growths into lumen; usually low grade
• Flat/Sessile - Carcinoma in Situ (CIS) - flat, high-grade, aggressive

1. Urothelial Papilloma - benign, normal nuclei, no mitoses
2. PUNLMP (Papillary Urothelial Neoplasm of Low Malignant Potential) - low risk of recurrence, no progression
3. Low-grade urothelial carcinoma - some nuclear variation, occasional mitoses
4. High-grade urothelial carcinoma - moderate-marked nuclear pleomorphism, many mitoses

• Squamous differentiation
• Glandular/adenomatous differentiation
• Micropapillary variant (aggressive)
• Plasmacytoid variant
• Sarcomatoid variant
• Small cell / neuroendocrine component
• These variants carry worse prognosis and more likely to metastasise to peritoneum

B. Squamous Cell Carcinoma (SCC) - 6-8%

• Associated with schistosomiasis, chronic UTI, bladder calculi, indwelling catheters
• More common in Middle East/Africa
• Typically high grade, infiltrating, worse prognosis than TCC

C. Adenocarcinoma - 2%

• Arises from urachal remnant (commonest primary site) or metaplastic glandular change
• Also seen in bladder exstrophy
• Glandular, mucin-secreting tumour
• Urachal adenocarcinoma occurs at the dome of the bladder

D. Rare Types

• Small cell carcinoma - very aggressive, neuroendocrine
• Pheochromocytoma - rare paraganglioma
• Primary lymphoma, sarcoma - extremely rare

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3. CLINICAL FEATURES

Symptoms

1. Painless haematuria - hallmark symptom, present in 85% of cases
   • May be frank (macroscopic) or microscopic
   • Typically intermittent, total (throughout micturition)
   • 12-20% of patients with macroscopic haematuria have bladder cancer
   • "Any adult with haematuria must be investigated for bladder cancer"
2. Storage LUTS (especially with CIS):
   • Frequency - increased daytime micturition
   • Urgency - sudden urge to void
   • Dysuria - burning on urination
   • Recurrent UTIs - especially in women

Signs

• Often no abnormal signs in early disease
• Suprapubic mass - in advanced local disease (large tumour)
• Palpable lymph nodes - inguinal, iliac in advanced disease
• Bimanual examination under anaesthesia (EUA):
  • Palpable mass suggests T3 or more
  • Fixed mass indicates T4 disease (invasion of pelvic wall)

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4. TNM STAGING CLASSIFICATION (AJCC 2017)

T - Primary Tumour

N - Regional Lymph Nodes

• N0 = No lymph node involvement
• N1 = Single lymph node in true pelvis
• N2 = Multiple lymph nodes in true pelvis
• N3 = Common iliac lymph nodes

M - Distant Metastasis

• M0 = No distant metastasis
• M1 = Distant metastasis (liver, lung, bone)

Stage Grouping

Key concept: Tis + Ta + T1 = Non-Muscle-Invasive Bladder Cancer (NMIBC) - 70% at presentation T2 + T3 + T4 = Muscle-Invasive Bladder Cancer (MIBC) - 30% at presentation

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5. DIAGNOSTIC TESTS

A. Urine Tests

• Dipstick: detects haematuria (blood), protein, leucocytes, nitrites (infection)
• Microscopy: RBCs confirm haematuria; WBCs suggest infection
• Note: even microscopic haematuria (>3 RBC/HPF) requires investigation in adults

• Rules out UTI as cause of haematuria/LUTS
• Mandatory before cystoscopy

• Exfoliated tumour cells in voided urine examined microscopically
• Sensitivity: very good for high-grade tumours and CIS (~90% positive in CIS)
• Poor sensitivity for low-grade papillary tumours (~10-40%)
• High specificity when positive (>90%)
• Reported using Paris System:
  • Negative for HGUC
  • Atypical urothelial cells
  • Suspicious for HGUC
  • Positive for HGUC (High-Grade Urothelial Carcinoma)
• Cannot rule out bladder cancer if negative

• NMP22 (Nuclear Matrix Protein 22) - sensitivity 69%, specificity 77%
• BTA (Bladder Tumor Antigen) test - detects human complement factor H protein
• FISH (Fluorescence In Situ Hybridisation) - detects chromosomal abnormalities in cells
• None has been shown to replace cystoscopy accuracy

B. Imaging Studies

• First-line investigation for haematuria in many centres
• Can detect bladder tumours >0.5 cm (intravesical mass)
• Also assesses kidneys (hydronephrosis, upper tract disease)
• Limitation: cannot reliably detect flat lesions (CIS) or small tumours

• Gold standard for upper tract disease evaluation
• Assesses: urothelial tumours of renal pelvis/ureter, hydronephrosis, lymph node metastases
• Uses: pre-contrast + corticomedullary phase + excretory phase (5-15 min post-contrast)
• Enhanced bladder tumours show increased enhancement vs. surrounding urothelium
• Must be performed BEFORE TURBT - post-TURBT inflammation can cause false-positive T3 staging
• CT chest for complete staging in confirmed cases

• Superior to CT for local tumour staging (T-staging)
• Uses multiparametric approach; best assesses depth of wall invasion
• MRI is preferred when precise T-staging is needed before cystectomy
• Useful for: T2 vs T3 differentiation, seminal vesicle/vaginal invasion assessment

• Traditional; now largely replaced by CTU
• Only 60% of bladder cancers visible on IVU
• Useful for identifying filling defects in bladder

• For bone metastases if bone pain or elevated alkaline phosphatase

• For lung metastases; mandatory in confirmed MIBC

C. Cystoscopy (GOLD STANDARD for Diagnosis)

• Mainstay of diagnosis - most sensitive and specific
• Direct visualisation of bladder mucosa
• Performed first in all patients with haematuria

• Papillary tumours: frond-like, cauliflower-like projections; usually low-grade TCC
• Sessile/nodular tumours: flat or raised, broad base, more aggressive
• CIS: red, velvety patch of mucosa ("raspberry patch") - easily missed
• Tumour location: trigone, lateral walls most common; posterior wall, dome
• Size, number, mobility of tumour

• Narrow Band Imaging (NBI): optical enhancement, improves detection of flat lesions and CIS
• Photodynamic Diagnosis (PDD) / Blue Light Cystoscopy: uses hexaminolevulinate photosensitiser; tumour cells fluoresce pink-red under blue light
• Recommended when: positive cytology + negative white-light cystoscopy; high suspicion of cancer

• Performed when tumour identified on flexible cystoscopy
• Bimanual examination under anaesthesia before and after resection
• Systematic mapping biopsies if CIS suspected (trigone, dome, right/left/anterior/posterior walls)

D. Biopsy / Histopathology (TURBT Specimen)

• Provides tissue for histopathological diagnosis and staging
• Must include detrusor muscle in specimen to assess muscle invasion (T2 staging)
• For large tumours: fractionated resection of tumour + base with deep muscle
• For small tumours (<3 cm): en-bloc resection preferred

1. Tumour type - urothelial, squamous, adenocarcinoma
2. Grade - G1 (well), G2 (moderate), G3 (poorly differentiated) or Low/High grade (WHO 2016)
3. Depth of invasion - Ta, T1, T2 (determines management)
4. Presence of CIS - flat high-grade component
5. Presence of muscularis propria (detrusor muscle) in specimen
6. Variant histology - divergent differentiation

• CK7, CK20 - confirm urothelial origin
• p53 - TP53 mutation; poor prognosis marker
• Ki-67 - proliferation index; high in high-grade tumours
• GATA3, Uroplakin - urothelial carcinoma markers
• Synaptophysin, chromogranin - for neuroendocrine/small cell component
• CDX2 - adenocarcinoma differentiation
• Useful in poorly differentiated tumours and metastases to confirm bladder origin

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6. MANAGEMENT

Overview by Stage

NMIBC (Tis, Ta, T1) → TURBT + Intravesical Therapy + Surveillance
MIBC (T2-T4, N0, M0) → Neoadjuvant Chemotherapy + Radical Cystectomy
Advanced/Metastatic → Systemic Chemotherapy / Immunotherapy

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A. Management of Non-Muscle-Invasive Bladder Cancer (NMIBC)

Step 1: TURBT (Always first)

• Initial management for all bladder tumours
• Rigid cystoscope under general anaesthesia
• Bimanual EUA before and after resection
• Must include muscle in specimen
• Record: size, number, papillary/nodular, CIS presence, completeness of resection

Step 2: Immediate Post-TURBT Intravesical Mitomycin C

• Single dose instilled into bladder within 24 hours of TURBT
• Reduces early recurrence risk by 12%
• Do NOT give if suspected bladder perforation during resection

Step 3: Risk Stratification & Further Treatment

Intravesical BCG (Bacillus Calmette-Guerin)

• For high-risk NMIBC
• Immunotherapy: activates local immune response against tumour cells
• Induction: 6 weekly instillations
• Maintenance: 3 weekly instillations at 3, 6, 12, 18, 24, 30, 36 months
• Reduces progression to MIBC
• Side effects: dysuria, frequency, haematuria, BCG sepsis (rare)
• Decreased efficacy in elderly patients

Repeat TURBT (Re-TUR)

• For high-grade or T1 tumours: repeat TURBT 2-6 weeks after initial
• Identifies residual tumour
• Upstaging to MIBC found in up to 40% of T1 tumours on re-TUR

Surveillance after NMIBC

• Regular flexible cystoscopy at 3 months, then 6-12 monthly
• Urine cytology at each visit
• Recurrence rate: 70% within 3 years

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B. Management of Muscle-Invasive Bladder Cancer (MIBC) - T2-T4

Step 1: Complete Staging

• CT abdomen + pelvis + chest
• MRI bladder for precise T-staging
• Bone scan if symptomatic

Step 2: Neoadjuvant Chemotherapy

• Cisplatin-based combination chemotherapy (MVAC or GC regimen) before surgery
• Improves overall survival by ~5-8% at 5 years (absolute benefit)
• Benefit from tumour downstaging before cystectomy
• Given for 3-4 cycles over ~3 months before surgery

Step 3: Radical Cystectomy (Gold Standard for MIBC)

• Removal of: bladder, prostate, seminal vesicles, proximal urethra
• Bilateral pelvic lymphadenectomy (external iliac, internal iliac, obturator nodes)

• Removal of: bladder, uterus, ovaries, anterior vaginal wall, urethra

• Open (traditional), Laparoscopic, or Robotic-assisted (increasingly standard)
• Evidence for superiority of minimally invasive over open is awaited

Step 4: Urinary Diversion (after cystectomy)

• Ureteroileal leak or stricture
• Urinary leak
• Stone formation in pouch
• UTI
• Metabolic: hyperchloraemic metabolic acidosis (common with ileal pouches)
• Stenosis/incontinence (up to 50% revision in 5 years)
• Rare: adenocarcinoma in pouch (~5%)

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C. Bladder-Sparing Options (for selected MIBC patients)

Radical Radiotherapy

• For elderly/unfit patients unsuitable for radical cystectomy
• 66 Gy in 30 fractions over 6 weeks
• Side effects: long-term urinary and bowel dysfunction; risk of secondary malignancy; fistula risk

Trimodality Therapy (Bladder Preservation Protocol)

• Radical TURBT + neoadjuvant chemotherapy + chemoradiotherapy
• For highly selected patients with localised MIBC
• Not standard; considered experimental

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D. Advanced / Metastatic Bladder Cancer

First-Line Chemotherapy

• GC (Gemcitabine + Cisplatin) - equally effective as MVAC, less toxic
• MVAC (Methotrexate, Vinblastine, Adriamycin, Cisplatin)
• For cisplatin-ineligible patients: Carboplatin + Gemcitabine

Immunotherapy (Checkpoint Inhibitors)

• Pembrolizumab (anti-PD-1), Atezolizumab, Nivolumab
• For second-line treatment or platinum-ineligible patients
• Based on PD-L1 expression

Targeted Therapy

• Erdafitinib (FGFR inhibitor) - for FGFR2/3 altered urothelial carcinoma

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Quick Summary Table

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